Dose Escalation for Patients With Locally Advanced Nasopharyngeal Carcinoma Treated With Radiotherapy Alone

Exploring MRI based radiomics analysis of intratumoral spatial heterogeneity in locally advanced nasopharyngeal carcinoma treated with intensity modulated radiotherapy

Background

We hypothesized that spatial heterogeneity exists between recurrent and non-recurrent regions within a tumor. The aim of this study was to determine if there is a difference between radiomics features derived from recurrent versus non recurrent regions within the tumor based on pre-treatment MRI.

Methods

A total of 14 T4NxM0 NPC patients with histologically proven “in field” recurrence in the post nasal space following curative intent IMRT were included in this study. Pretreatment MRI were co-registered with MRI at the time of recurrence for the delineation of gross tumor volume at diagnosis(GTV) and at recurrence(GTVr). A total of 7 histogram features and 40 texture features were computed from the recurrent(GTVr) and non-recurrent region(GTV-GTVr). Paired t-tests and Wilcoxon signed-rank tests were carried out on the 47 quantified radiomics features.

Results

A total of 7 features were significantly different between recurrent and non-recurrent regions. Other than the variance from intensity-based histogram, the remaining six significant features were either from the gray-level size zone matrix (GLSZM) or the neighbourhood gray-tone difference matrix (NGTDM).

Conclusions

The radiomic features extracted from pre-treatment MRI can potentially reflect the difference between recurrent and non-recurrent regions within a tumor and has a potential role in pre-treatment identification of intra-tumoral radio-resistance for selective dose escalation.

Adenoid Cystic Carcinoma of the Lacrimal Gland: High Dose Adjuvant Proton Therapy to Improve Patients Outcomes

Introduction: Lacrymal cystic adenoid carcinoma is a rare disease for which optimal treatment is still debated. In fact, despite aggressive treatment such as eye sparing surgery or orbital exenteration, following by adjuvant radiotherapy, local recurrence and distant metastatic disease are common. This study aims to describe outcomes of eye surgery associated with high dose exclusive adjuvant proton beam irradiation. Materials and Methods: This is a monocentric institutional retrospective study. We retrospectively reviewed records of patients treated in our institution since 2008 with high dose adjuvant proton irradiation for a lacrymal cystic adenoid carcinoma up to a maximum of 75.6Gy(RBE). Other histologies or patients treated with a mix of photon-proton were excluded. A total of 15 patients were finally included. Results: Fifteen patients (80% women, 100% Performance status 0-1) with locally advanced disease (33% T3-T4, 47% R1-R2) were included. After a median follow-up of 67.4 months [13.4-122] the 3 years Overall Survival, local Progression free survival, and progression free survival rates were 78, 70, and 58%, respectively. Six patients exhibited a local recurrence. All patients with conservative surgery maintained their base-line visual acuity and visual field at last follow up. Four patients developed brain radionecrosis. Conclusion: This is the largest series of patients with ACC treated with high dose adjuvant proton therapy. Proton therapy is a safe and efficient treatment and should be considered as an adjuvant irradiation modality to privilege, for patients with lacrimal ACC after conservative or radical eyeball surgery. Dose delivered to temporal lobe should be limited to avoid brain radionecrosis.

Locoregionally advanced nasopharyngeal carcinoma treated with intensity-modulated radiotherapy plus concurrent weekly cisplatin with or without neoadjuvant chemotherapy

Purpose

The outcomes of locoregionally advanced nasopharyngeal carcinoma patients treated with concurrent chemoradiation (CCRT) using intensity-modulated radiotherapy (IMRT) with/without neoadjuvant chemotherapy (NCT) were evaluated.

Materials and Methods

Eighty-three patients who underwent NCT followed by CCRT (49%) or CCRT with/without adjuvant chemotherapy (51%) were reviewed. To the gross tumor, 67.5 Gy was prescribed. Weekly cisplatin was used as concurrent chemotherapy.

Results

With a median follow-up of 49.4 months, the 5-year local control, regional control, distant metastasis-free survival (DMFS), disease-free survival (DFS), and overall survival rates were 94.7%, 89.3%, 77.8%, 68.0%, and 81.8%, respectively. In multivariate analysis, the American Joint Committee on Cancer stage (p = 0.016) and N stage (p = 0.001) were negative factors for DMFS and DFS, respectively. Overall, NCT demonstrated no benefit and an increased risk of severe hematologic toxicity. However, compared to patients treated with CCRT alone, NCT showed potential of improving DMFS in stage IV patients.

Conclusion

CCRT using IMRT resulted in excellent local control and survival outcome. Without evidence of survival benefit from phase III randomized trials, NCT should be carefully administered in locoregionally advanced nasopharyngeal carcinoma patients who are at high-risk of developing distant metastasis and radiotherapy-related mucositis. The results of ongoing trials are awaited.

Current management of nasopharyngeal cancer

Management of nasopharyngeal carcinoma is one of the greatest clinical challenges. Appropriate detection is not easy because of its anatomical location; sensitive biomarkers in addition to endoscopic and radiological examinations would be valuable. One useful biomarker (particularly for nonkeratinizing carcinoma) is the plasma level of Epstein-Barr viral deoxyribonucleic acid, and its role as a tool for prognostication and monitoring disease progress is presented. Radiotherapy is the primary treatment modality, and using radiation therapy in combination with chemotherapy is recommended for the treatment of locoregionally advanced tumors. Intensity-modulated radiotherapy techniques with image guidance to ensure setup precision are recommended if resources allow; adaptive replanning should be considered if major deviations from the intended dose distribution occur during the treatment course. Most contemporary series have reported encouraging results, with locoregional control exceeding 90%; the key problem is distant failure. The therapeutic margin is extremely narrow. Although significant reduction of some toxicities (eg, xerostomia) and better quality of life is now achievable especially for early stages, the risk of major late toxicities remains substantial. This review will focus on the primary treatment: the current consensus and controversies in the treatment strategy for different stages, the choice of chemotherapy regimen, and the key factors for improving the therapeutic ratio of radiotherapy will be discussed. Summary of the current achievement and direction for future improvement will be presented.

Outcomes following treatment for patients with cranial nerve involvement from nasopharyngeal cancer

INTRODUCTION

Patients with locally advanced nasopharyngeal carcinoma (NPC) commonly present with cranial nerve (CN) involvement, which can cause significant morbidity. We aimed to characterise the pattern of involvement and outcomes of these patients, as well as determine if these differed according to the mode of diagnosis.

METHODS

Patients were included if they had non-distant metastatic NPC, presented with CN involvement and completed radiotherapy treatment between 2002 and 2008. The clinical response was categorised as complete response, partial response, stable or progressive disease. The radiological response was assessed using the Response Evaluation Criteria in Solid Tumors criteria. The loco-regional control and disease-free survival rates were estimated with the Kaplan-Meier method.

RESULTS

Forty-seven patients fulfilled the inclusion criteria. CN lesions were diagnosed on clinical examination in 15% of patients, radiologically in 40% and both clinically and radiologically in 45% of patients. A complete or partial response of the CN lesions was seen clinically in 82% and radiologically in 95% of patients. The 3-year local relapse free survival was 64.3%, distant metastasis-free survival was 46.1% and overall survival was 82.8%. There were no differences in outcomes between patients with clinically versus radiologically detected CN lesions.

CONCLUSION

Most of these patients are likely to undergo clinical and/or radiological resolution of the nerve lesions following chemoradiotherapy, but the outcome was not determined by the mode of diagnosis (radiological or clinical).

Post-treatment late complications of nasopharyngeal carcinoma

Radiotherapy (RT) or concurrent chemoradiation therapy (CCRT) is not only effective at patients' survival rates, but also produces undesirable late complications. The purpose of this study is to investigate the post-treatment late complications in nasopharyngeal carcinoma (NPC) patients, and to analyze the individual impact factors. We enrolled 188 newly diagnosed NPC patients who had received complete treatments and at least 3 years' follow-up between March 1984 and March 2010. Late complications were modified from the Toxicity Criteria of the Radiation Therapy Oncology Group and the European Organization for Research and Treatment of Cancer. Of 188 patients, 132 were male and 56 were female. Eighty-eight patients received CCRT and the other 100 patients received RT alone. The median follow-up duration was 7.34 years (range 3.30-26.54). Only 5.3% of patients reported no complication during post-treatment follow-up. The most common major and minor complications were osteoradionecrosis (10.1%) and xerostomia (56.4%), respectively. There was no impact factor for age, underlying disease, and cancer staging. However, there was a negative impact factor for xerostomia and limb numbness in the CCRT group compared with the RT group. Besides, re-radiation for recurrent patients could increase the risk of major complications. Fortunately, these major complications were reduced after the introduction of intensity-modulated radiotherapy in 2003. The improvement of treatment modality decreased the risk of major complications. Physicians should pay more attentions and improve patients' quality of life during follow-up.

A systematic review of salivary gland hypofunction and xerostomia induced by cancer therapies: prevalence, severity and impact on quality of life

PURPOSE

This systematic review aimed to assess the literature for prevalence, severity, and impact on quality of life of salivary gland hypofunction and xerostomia induced by cancer therapies.

METHODS

The electronic databases of MEDLINE/PubMed and EMBASE were searched for articles published in English since the 1989 NIH Development Consensus Conference on the Oral Complications of Cancer Therapies until 2008 inclusive. Two independent reviewers extracted information regarding study design, study population, interventions, outcome measures, results and conclusions for each article.

RESULTS

The inclusion criteria were met by 184 articles covering salivary gland hypofunction and xerostomia induced by conventional, 3D conformal radiotherapy or intensity-modulated radiotherapy in head and neck cancer patients, cancer chemotherapy, total body irradiation/hematopoietic stem cell transplantation, radioactive iodine treatment, and immunotherapy.

CONCLUSIONS

Salivary gland hypofunction and xerostomia are induced by radiotherapy in the head and neck region depending on the cumulative radiation dose to the gland tissue. Treatment focus should be on optimized/new approaches to further reduce the dose to the parotids, and particularly submandibular and minor salivary glands, as these glands are major contributors to moistening of oral tissues. Other cancer treatments also induce salivary gland hypofunction, although to a lesser severity, and in the case of chemotherapy and immunotherapy, the adverse effect is temporary. Fields of sparse literature included pediatric cancer populations, cancer chemotherapy, radioactive iodine treatment, total body irradiation/hematopoietic stem cell transplantation, and immunotherapy.